A surgeon takes aim at bias in health care

If you log onto MEDLINE and search for papers by Augustus A. White III, M.D., Ph.D., HS ’66, most citations will be what you’d expect from a prominent orthopaedic surgeon, with titles like “Effect of Screw Diameter, Insertion Technique and Bone Cement Augmentation of Pedicular Screw Fixation Strength.” But among the recent articles, you’ll also find one with a very different focus, “Our Humanitarian Orthopaedic Opportunity.” In the March 2002 issue of The Journal of Bone & Joint Surgery, White addresses topics that have increasingly preoccupied him during four decades as a surgeon: the racism that has denied equal health care to African-Americans and the healing potential of cultural sensitivity among doctors.

Unless physicians fight their conscious and unconscious biases, White says, they will widen the gap between the quality of health care provided to the privileged and what’s offered to the marginalized. Infant mortality rates show that things are getting worse, says White, the Ellen and Melvin Gordon Professor of Medical Education at Harvard, where he is also a professor of orthopaedic surgery. In 2000, 14 of every 1,000 black babies died in their first year, compared with 5.7 per 1,000 white babies. That ratio of 2.5 black deaths for each white death has increased over the past 20 years, from 2.0, according to the Centers for Disease Control and Prevention. “Bias is thoroughly interwoven into the very core of Western medical culture,” says White, former orthopaedic surgeon-in-chief at Boston’s Beth Israel Deaconess Medical Center.

Even after adjusting for education and access to care, studies show similar gaps. African-Americans are less likely than whites to have coronary angiography, drug therapy for HIV, kidney transplantation and even routine care. Bias even seems to influence the decisions of African-American physicians themselves. A 2001 Yale study by Jersey Chen, M.P.H. ’98, M.D. ’00, and Harlan M. Krumholz, M.D., professor of medicine, and others showed that after an acute myocardial infarction, white patients were significantly more likely than blacks to be given cardiac catheterization, even when the African-American patients were treated by African-American doctors. “Does anyone still have doubts about the momentum for bias in our medical heritage?” White asks.

He says that when the physician workforce represents a variety of ethnic groups, health care improves for those less likely to get good care. Physicians from minority groups are more likely to set up practices in underserved areas; simply including them on a team improves care, says White, who is African-American. “Over time, you’re going to have a team that’s less ethnocentric.”

White believes that awareness of cultural differences is slowly emerging. At Harvard, first-year medical students now attend an all-day discussion of cultural differences in medicine. He describes his Yale mentor, Wayne O. Southwick, M.D., professor emeritus of orthpaedics, as a leader in fostering gender and racial diversity. Southwick received the 2003 Diversity Award from the American Academy of Orthopaedic Surgeons for his commitment to achieving greater diversity in the field.

White experienced racism in medicine firsthand when he graduated from Brown University in 1957 and sought a summer hospital job. At the “white” hospital in his hometown of Memphis, he would have been restricted to a menial job. To find a job with responsibility, White had to apply to a hospital for nonwhite patients; there he was allowed to work as a surgical technician. Since then, “the theme of diversity and the value and importance of diversity” has been “a recurrent theme in my mind, like a Bach concerto.

White is co-author, with Manohar M. Panjabi, Ph.D., a Yale professor of orthopaedics and mechanical engineering, of the widely used reference Clinical Biomechanics of the Spine and author of the popular book Your Aching Back: A Doctor’s Guide to Relief. Although White no longer performs surgery, he still does consultations, writes about orthopaedics and lectures both at Harvard and at national conferences. He has won many awards, including the Bronze Star for service as an Army surgeon in Vietnam. A former Brown University corporation trustee and fellow, he was selected in 2000 as one of Brown’s 100 most influential 20th-century graduates, chosen from among 75,000 alumni. When asked what honor has given him the greatest satisfaction, White replied, “What’s clearly the most gratifying is the positive feedback from patients, spine fellows, professional colleagues.” He said he was reminded of his purpose when he read The Art of Happiness: A Handbook for Living by the Dalai Lama, adding, “Our purpose here on Earth is to be happy, and the way to be happy is to help others.” White also finds happiness listening to the music of Duke Ellington, Quincy Jones and Nina Simone at home in Weston, Mass., where he lives with his wife, Anita, and two of his three grown daughters. (The third daughter is working in Sweden, where White studied and met his wife.)

In his article on race and medical care, White asks physicians to approach every patient based on the “double F criterion”—that is, to ask themselves: “Is this the way I would treat my friend or my family?” Do this, writes White, “and we make a tremendous contribution toward the elimination of health care disparities.”